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Rural Farm & Land Liability

NEW ZEALAND NATIONWIDE INSURANCE BROKER SERVICES
Auckland • Wellington • Christchurch • Dunedin • Queenstown • Gisborne

RuralPlus Farm & Vacant Land Public Liability Insurance

PROPOSAL FORM

Public and Liability Insurance Only

Terms and Conditions

TYPE OF PROPERTY & USES -

Section 1

Unoccupied Land

Hobby Farm

Working Farm

Other


Is the Property located in:-	a suburb of a City or Town	a Rural Area (not in a suburb of a City or Town)

What is the address of the Property to be insured - and - what size is the property

Is any Commercial Enterprise carried on at or from the property

If Yes, please tell us about the type of Commercial Enterprise carried on

Are any livestock kept on the property

If Yes, please tell us the type of livestock (cattle, horses, goats etc') and how many of each type (close approximation) and whether or not you own the livestock or if such are agisted

Are any Unregistered Vehicles, such as tractors and/or motor bikes for example, used on the property

Are Firearms kept at and/or used on the property

If Yes, are all firearm users legally licensed to use, operate and keep a firearm at the property

Please tell us a bit more about the property so we can better understand the types of activities that take place on the property and the reasons you wish to insure it


What date would you like Cover to start from? - or What is the Expiry Date of your current insurance?	DD / MM / YYYY

LIMITS OF COVER - AND - PREMIUMS:- $10 MILLION PUBLIC LIABILITY COVER-

Section 2

Types of Property	up to 4Ha	5 to 50Ha	51 to 200Ha	201 to 500Ha

Unoccupied Land (Suburban location)	$310	on application	on application	on application	Please Select the Cover & Premium Required Premium Rates (Includes Broker Fees & Statutory Charges)
Unoccupied Land (Rural Location)	$290	$330	$380	$510
Hobby Farm (Occupied Part Time)	$300	$350	$410	$570
Working Farm (Occupied Full Time)	$405	$480	$610	$710

Standard Claim Excess: $500.00

For Larger Areas or other Uses please contact us

PROPOSER DETAILS -

Section 3

Name :
		Name of person, company or entity seeking insurance
Address :
Suburb :		State : Postcode :
Phone :		Fax :
Email :

Have you or any person associated with this activity ever:-

had a Legal Liability claim made upon you or the other person?

ever made a claim for insurance in respect of the type of cover you require?

been refused insurance?

had an insurance claim of any type refused or reduced?

been charged with a crime of any type?

Depending on your answers to these five questions we may need to contact you for further information

DISCLOSURE AND ACKNOWLEDGEMENT DETAILS -

Section 4


Please examine your Duty of Disclosure

Is there anything else you need to disclose to us?

If Yes, please write here what it is that you think we ought to know

I acknowledge I have read and I agree to the terms and conditions stated	Your Answer is Mandatory

CREDIT CARD DETAILS -

Section 5

Your credit card will not be processed until insurance cover is confirmed

Card Type

Please complete the authority below

Cardholder Name

Card Number

Expiry Date

Amount $

Thank you we will do our best to respond in the next few hours - but we may need to contact you for further information

For qualifications concerning the information on this page, please click here.